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Based on interview, policy and procedure review and clinical record review, it was determined a Registered Nurse (RN) did not evaluate the patient's pain level at discharge from the Prep Center for one of one (#2) surgical patient. The failed practice did not ensure Patient #2's status for discharge and tolerable pain was adequately evaluated before being sent home. The failed practice affected Patient #2 and was likely to affect any surgical patient. Findings follow:

A. Review of the Comfort Measures Information sheet revealed there was no evidence the patient's level of pain was assessed at discharge. During an interview with the Director of Surgical Services at 0900 on 01/15/15, she stated Patient #2's last pain score was documented in PACU (Post Anesthesia Care Unit).
B. Review of the policy and procedure titled "Standard of Post Anesthesia Nursing Practice - Phase II" received from the Director of Surgical Services at 0830 on 01/15/15 revealed the following under Discharge Assessment: Phase II, ...#9: Adequate pain control ..."
C. The Director of Surgical Services was interviewed at 0900 on 01/15/15 and the findings in A and B were verified.